The Role of Neurorehabilitation in Post-COVID-19 Syndrome 2023, Diem et al

Sly Saint · May 11, 2023

Abstract:
Post-COVID-19 syndrome is an ongoing challenge for healthcare systems as well as for society. The clinical picture of post-COVID-19 syndrome is heterogeneous, including fatigue, sleep disturbances, pain, hair loss, and gastrointestinal symptoms such as chronic diarrhea. Neurological complaints such as fatigue, cognitive impairment, and sleep disturbances are common. Due to the short timeframe of experience and small amount of evidence in this field, the treatment of post-COVID-19 syndrome remains a challenge. Currently, therapeutic options for post-COVID-19 syndrome are limited to non-pharmaceutical interventions and the symptomatic therapy of respective symptoms. In this article, we summarize the current knowledge about therapeutic options for the treatment of neurological symptoms of post-COVID-19 syndrome.

https://www.mdpi.com/2514-183X/7/2/13

3. Treatment of Post-COVID-19 Neurological Symptoms
Currently, therapeutic options for post-COVID-19 syndrome are limited to non-drug measures or the symptomatic therapy of symptoms. One of the greatest therapeutic challenges is treating neurological symptoms.
In this section, we focus on the treatment of the three most frequent neurological symptoms: fatigue, pain, and sleep disorders.
In the last 2 years, there has been an increase in the number of studies on non-drug interventions for fatigue [26,27]. In addition, lessons could be learned from the experience of treating fatigue in other conditions such as multiple sclerosis, chronic fatigue syndrome, and cancer-associated fatigue.
However, we have to be very careful, because not all known therapeutic options for fatigue can be applied to post-COVID-19 fatigue. In contrast to the role of exercise in MS fatigue, in post-COVID-19 patients, due to post-exertional malaise, the anaerobic threshold does not need to be exceeded.
For the treatment of the other symptoms, we also refer to the recommendations of other guidelines from different countries, such as the NICE guidelines (UK) or S1 guidelines (Germany) [28,29].
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CBT for severe fatigue has been found to be effective in several randomized controlled trials [34,35,36]. A recent multicenter two-arm randomized controlled trial (ReCOVer study) tested the efficacy of a program with CBT in patients experiencing severe post-infectious fatigue after a COVID-19 infection [37]. This program, named Fit after COVID-19, consists of up to nine modules ((1) goal setting; (2) sleep–wake pattern; (3) helpful thinking; (4) social support; (5) graded activity; (6) processing the acute phase of COVID-19; (7) fear and worries regarding COVID-19; (8) coping with pain; and (9) realizing goals). The results have not yet been published, but recruitment is completed and will represent a milestone in post-COVID-19 treatment.
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3.2.1. Graduated Exercise Therapy
A systematic review of graduated exercise therapy (GET) for chronic fatigue syndrome (CFS) concluded that patients with CFS generally feel less fatigued and their sleep and physical function improve after completing graduated exercise therapy [38]. Since the update of the NICE guidelines in 2020, GET is no longer recommended. The NICE guidelines do not recommend GET because this treatment is considered to be ineffective and harmful based on evidence from patient surveys and qualitative studies [39]. This decision has been widely criticized by the scientific community due to the choice of analyzed studies [40,41]. In addition, the omission of a recently published meta-analysis of the safety results from ten published studies on GET was strongly objected to [42]. This study showed that GET is safe as long as it is prescribed properly [42].

However, it is essential that physical activity be adjusted to the individual’s limit to avoid triggering severe post-exertional malaise. It is therefore imperative to determine the limit of each patient before starting physiotherapy treatment. In the presence of post-exertional malaise, activity management or pacing [43,44], as well as heart rate monitoring [45], may be effective rehabilitation approaches to support the self-management of symptoms.

3.2.2. Pacing
Pacing is a prudent use of resources on a physical, mental, and emotional level. The goal of pacing is to find the optimal and individual balance between rest periods and activation periods (physical, cognitive, and emotional) [43,44].
The sustained stabilization of symptoms, which often fluctuate, could guide how activities and rest are modified in response to the individual and frequently subjective symptoms. Quality of rest, sleep, and eating habits can also be considered as part of activity management and may help in the stabilization of symptoms.
Pacing should include setting realistic goals, monitoring physical, cognitive and social activities and their impact on energy levels, and avoiding possible overexertion that could exacerbate symptoms. Pacing is not an activity avoidance strategy, but a strategy to minimize the worsening of symptoms after exertion [44,46]. Pacing is often used as part of a set of energy conservation strategies called the “Principle of Three P’s”, namely, prioritization, planning, and pause management [47].

3.3. Heart Rate Monitoring
Heart rate monitoring is a rehabilitation strategy that can be used by people to self-manage symptoms when living with post-COVID-19 syndrome. Heart rate monitoring is a useful method for people with fatigue to avoid PEM. It refers to the continuous measurement of heart rate with a heart rate monitor, and it is used to more accurately pace daily activities and monitor the body’s responses to exertion. The aim of heart rate monitoring is to stay below the ventilatory anaerobic threshold (VAT) throughout the day, thus avoiding post-exertional malaise [45]. The exact determination of VAT is carried out with the help of a cardiopulmonary exercise test (spiroergometry). However, this test can lead to post-exertional malaise in some patients. The pulse–threshold rate can also be calculated as an alternative. The Workwell Foundation recommends two methods for calculation [47]:
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(220 − age) × 0.55 = guideline (in beats per minute (bpm));
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Resting heart rate as a measure for activity management. Resting heart rate can be determined by having the person lie flat in bed and calculating the average resting heart rate over 7 days. The benchmark is now set as 15 bpm above the resting heart rate.
Before using heart rate monitoring, autonomic dysfunction (e.g., postural tachycardia syndrome) in the context of post-COVID-19 syndrome must be ruled out, as this makes the use of these methods impractical.
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Sly Saint · May 12, 2023

3.2.1. Graduated Exercise Therapy
A systematic review of graduated exercise therapy (GET) for chronic fatigue syndrome (CFS) concluded that patients with CFS generally feel less fatigued and their sleep and physical function improve after completing graduated exercise therapy [38].
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the paper cited is the criticism of the new NICE guidelines

"Flottorp, S.A.; Brurberg, K.G.; Fink, P.; Knoop, H.; Wyller, V.B.B. New NICE guideline on chronic fatigue syndrome: More ideology than science? Lancet 2022, 399, 611–613. [Google Scholar] [CrossRef] [PubMed]"

which cites the Cochrane review
(so this must be the 'systematic review' they refer to).

@Caroline Struthers

This study showed that GET is safe as long as it is prescribed properly [42].
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this study is here
https://www.tandfonline.com/doi/abs/10.1080/09638288.2018.1504994

eta: thread here https://www.s4me.info/threads/effec...nalysis-2018-hettinga-et-al.6817/#post-123462

Peter Trewhitt · May 12, 2023

Rehabilitation seems to be basically establishing what patients can and can not do, then getting them to practice what the can do just below the level of what they can’t do and then increase the intensity or the complexity of the practice gradually. Though I have never worked long term in a rehab unit/ward my recollection from my student placement days some forty years ago is that as long as improvement seems to be happening rehab continues, but when improvement stops rehab is tailed off. This is a bit of an oversimplification, but I suspect rehab largely continues on the same lines.

Graded exercise therapy or variants there of continue in the same model, without addressing why or why not it may be relevant for individual conditions or patients.

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